Two years ago in New Orleans, when I was elected second vice-president, a
member whom I had not met before approached me. After we exchanged
pleasantries and congratulations, he said something that at first took me by
surprise. But what he said resonated with what I already knew about the
importance of the leadership office I was about to assume. The member just
said, "Don't forget about me."
This simple statement, "Don't forget about me," captured the
essence of my office. The presidency of the American Academy of Orthopaedic
Surgeons (AAOS) is not about me. It is not about honors nor accolades. This
office is about the responsibility that I have to that member, to all of you,
to the other 28,000 members of this Academy, and to our future members.
My theme this year—"Nothing About You... Without
You"—is both a commitment and a call to action. The commitment and
call begin today, right now, with our Academy and with all of you. For the
coming year, as your president, I am committed to building upon the existing
strengths of our organization. By redoubling our efforts to meet the members'
needs, your needs, we will continue to set the pace for other societies in
other specialty disciplines.
Today, I will set forth an agenda that will ensure the continued
preeminence of our Academy in the medical community. For the coming year, with
the support of our strong Academy, I call upon you to join me in making a
collective professional commitment to do even more to improve the care we
provide to our patients. This year, I will be asking you to work with me, and
with the Academy, to create a culture of patient-centered care in our
organization and in our individual practices.
I know that my election to the presidency of the Academy gives me the
responsibility to meet your needs and enhance the value of your membership in
this Academy. But this office has a much broader reach than the fellowship. My
leadership responsibilities extend to enhancing the value of this Academy to
the millions of patients we serve. I must be responsive to the everchanging
needs and expectations of our patients and our members.
"Nothing About You... Without You" reflects the dual nature of
this responsibility—the responsibility that the Board and I, as leaders
of the Academy, have to you and the responsibilities that we collectively bear
as a profession to our patients.
Our job as the Academy's leaders is to ensure that our organization
provides you with the programs and services that you want and need. This
Academy must also remain proactive rather than reactive. Hence, we are
responsible not only for serving your current needs but also for anticipating
your future needs.
Over the past seven years, I have been privileged to work in
coalition-building on behalf of the Academy, first with the United States Bone
and Joint Decade and most recently with our national medical liability reform
coalition, Doctors for Medical Liability Reform. As I have worked with other
national medical specialty societies, I have become very aware that the
Academy is the model that other specialty societies wish to emulate. Other
organizations admire the breadth and depth of our members' commitment,
involvement, and leadership; our staff dedication and commitment; and the
actual tangible value that members derive from their dues. Our goal, through
continually assessing your needs, is to ensure that we maintain our leadership
in member benefits and organizational preeminence in the medical
community.
We are now in the midst of an intense two-year process of strategic
planning to chart our course for the end of the decade. Adding value to your
membership stands prominently in our goals. As always, we continue to seek
your input through your state orthopaedic society, through your Board of
Councilors' representatives, and through your specialty society
leadership.
We have regularly scheduled focus groups at the Orthopaedic Learning Center
and at the annual meeting. Our weekly presidential line conference calls
routinely include members randomly chosen from different sectors of the
Academy: residents, fellows, specialists, generalists, and emeritus members.
And this fall, many of you had the chance to participate in our member needs
assessment survey. This critical information will serve as the basis and
framework for our strategic planning process that will chart the course of the
Academy for the end of the decade. Over this next year, I will welcome your
input and encourage you to e-mail or write to me about your concerns.
Over the last twenty-five years, there have been dramatic technological
advances that have expanded the scope of practice in our specialty to
unparalleled levels. As a result, two-thirds of our members consider
themselves specialists or generalists with a specialty interest. We are now in
the midst of a biological revolution, which will no doubt change our practices
in ways we have yet to imagine. These developments will inevitably lead to the
continued subspecialization of orthopaedic surgery. There are many naysayers
who claim that further proliferation of subspecialties is bad for the Academy.
I disagree!
I believe that specialization offers unique opportunities for the Academy
to strengthen our orthopaedic foundation. We must, however, discourage the
parochial thinking that often accompanies specialization. Narrow thinking will
only weaken our specialty in every arena, from undergraduate and graduate
medical education to advocacy in health care and research funding. Therefore,
the Academy must strengthen the foundations of our specialty through
leadership in developing new ways to partner with specialty societies. Such
mutual benefit will bring synergy to our educational, advocacy, and
communication efforts, as well as eliminate needless and expensive
duplications.
If the current and future leaders of the specialty societies and this
Academy fail to capitalize on these synergies, we will see the crumbling of
our specialty's very foundation, increasingly fragmented care of patients with
musculoskeletal conditions, decreasing quality of musculoskeletal care, loss
of hard-won political capital, and the assumption of musculoskeletal care by
others who are better prepared to meet the health-care challenges of the
twenty-first century. We cannot, and in fact must not, fail in these unity
efforts!
In another arena, with a better-educated public and an increasing focus on
medical errors and accidents, everyone has begun looking for quality
assessment, including assessment of physician performance. Working under the
premise that value purchasing in health care should be the rule as it is in
other areas of industry, the United States business community has targeted
high-quality medical care as a significant
objective1,2.
To date, there are no valid and reliable methods of individual physician
performance assessment. Patients currently pay little attention to physician
scorecards or other measures that are part of the quality movement, but they
often use certification as a method of finding a good
doctor1,3.
A recent Gallup poll revealed that the public highly valued certification
and maintenance of certification (MOC) as indicators of
quality4,5.
In the view of many authorities, these "should be among the
evidence-based measures used in the quality
movement."1
As many of you know, the Federation of State Licensing Boards has set up a
special committee to review what state boards have done to ensure the
continuing competence of physicians. Several state licensing boards have
already set in motion requirements for physicians who do not hold a
certificate from an American Board of Medical Specialties board to be
reexamined in general medicine on a periodic basis. Hence, as Roby Thompson,
past Academy president, wrote in The Journal of Bone and Joint
Surgery recently, "A credible MOC program developed by orthopaedic
surgeons for orthopaedic surgeons would be far preferable to and more
effective than a general medical examination developed and administered at the
state
level."6
The Academy is refocusing our educational efforts to help members to meet
the challenge, to help our candidate members to become certified, and to help
all of our members to meet the requirements of MOC. As the MOC process
evolves, members can be assured that the Academy will help them to meet the
commitment to lifelong learning and periodic self-assessment mandated by the
MOC process. We will do so through a variety of programs and formats to suit
every preferred learning style.
Another challenge facing us is the fact that musculoskeletal diseases and
injuries are underappreciated, undervalued, and underresourced by those who
regulate health care, those who pay for health care, and those who allocate
research funding. To address this issue, the Academy played the leadership
role in organizing the Bone and Joint
Decade7.
One of our major accomplishments was developing compelling
burden-of-disease information to convince President Bush that the formal
proclamation of a Decade was worth supporting in order to raise the profile of
musculoskeletal
conditions8,9.
The Academy also cosponsored The Dartmouth Atlas of Musculoskeletal
Health Care, the seminal work that identifies practice variations and
disparities in musculoskeletal health care in this
country10. This
important work has been one of the prime stimuli for the current quality
movement in health care. To further focus policy makers on the national need
for musculoskeletal health care and research, the Academy and Dartmouth
University are producing a powerful tool to focus attention on this need.
Partnering with us are nationally recognized experts in the analysis and
presentation of health-care data from the Centers for Disease Control, Harvard
University, and University of California, San Francisco.
This important document will be the cornerstone for all of our advocacy
efforts regardless of arena. It will help to justify the expansion of our
specialty to meet the growing burden of musculoskeletal conditions, provide
supporting evidence for the expansion of musculoskeletal education in our
medical schools, further identify disparities in the treatment of
musculoskeletal conditions, and enhance funding in this area. This work will
provide important recognition of the orthopaedic community as leaders in
improving health care in this country. It will also provide the case statement
for increasing research dollars commensurate with the growing burden of
musculoskeletal disease.
Despite the increasing disparity between federal funds for musculoskeletal
research and the growing burden of musculoskeletal disease, we must remember
our good fortune. We have benefited from the visionary leadership of American
orthopaedics in the 1950s when the Orthopaedic Research and Education
Foundation (OREF) was established. As OREF celebrates its fiftieth anniversary
this year, we can look back proudly on its history of providing more than $58
million for orthopaedic research. These millions have funded more than 2100
research grants.
I cannot overemphasize the importance of supporting OREF for the future of
our specialty. While we all can't do research, we all can contribute to the
future of our specialty by making an annual contribution to OREF. This is the
one way that we all have to give something back to the specialty that has
given us so much and has helped us to improve the quality of life for millions
of patients.
In the advocacy arena, the Academy has played and will continue to play a
leadership role. Our efforts began in 1979 when we established our Washington
office to confront issues of musculoskeletal research funding. In 1997, the
Academy established the American Association of Orthopaedic Surgeons to meet
the ever-increasing advocacy needs of our members and our patients, and to
make these efforts more effective. This year, we will continue to expand our
advocacy efforts to the specialty societies. These efforts and the political
capital developed by the Academy over the last twenty-five years must be
strengthened by developing a unified, specialty-wide advocacy agenda.
The AAOS has played a leadership role among medical specialty societies in
founding and leading the major coalitions addressing the important global
issues of the day. We founded the NIAMS (National Institute of Arthritis and
Musculoskeletal and Skin Diseases) Coalition, the Practice Expense Coalition,
the Alliance for Specialty Medicine, and, most recently, Doctors for Medical
Liability Reform, a 230,000-physician-strong coalition with the sole goal of
bringing about federal medical liability reform.
The current medical liability crisis is profoundly changing the landscape
of American medicine and health-care delivery by limiting patient access to
care in a growing number of states. Access is affected because physicians
change their practices, eliminate high-risk procedures, stop emergency-room
coverage, eliminate trauma care, retire early, or move their practices to
states with more favorable medical liability climates. While all doctors are
affected, the high-risk specialties (orthopaedics, neurosurgery, obstetrics,
emergency medicine, and surgery) have been hit especially hard.
The most important relationship damaged by the current crisis is the
doctor-patient relationship. Many physicians now view patients as potential
adversaries11. Such
an attitude results in the ordering of unnecessary tests and studies,
dramatically increasing the cost of health care.
To give you an idea of the extent of the problem, as of July 2004, there
was no neurosurgical coverage in the southern half of the state of Illinois.
Kentucky had lost one-third of its obstetricians, and seventy counties there
were without obstetrical care. Two-thirds of the emergency rooms in this
country are at risk because of problems with the availability of on-call
specialty coverage.
One of the saddest aspects of the current crisis is its effect on the
career choices of medical students. Last year, only 65% of first-year
residencies in obstetrics and gynecology in the United States were filled by
American
graduates12.
In orthopaedic surgery, we still have an abundance of qualified applicants
but the liability crisis is palpably affecting their choice of specialties
within orthopaedics and their practice locations. The future is not bright
without a resolution of this problem.
The AAOS Board of Directors recognizes that the medical liability crisis is
the number-one issue affecting our members' ability to practice. The AAOS has
devoted considerable financial resources and has made a total organizational
commitment to achieve meaningful federal medical liability reform and
constitutionally sustainable state-level reform.
During this past election cycle, we were able to support orthopaedic
society campaign efforts to gain liability reform in all ten states that
applied for funds. I am very proud to say that we have been able to achieve
successes in five of those states, with substantial inroads made in others. We
will continue to help state orthopaedic societies in their quest to obtain
meaningful and constitutionally sustainable medical liability reform during
the next election cycle.
On the federal front, medical liability reform enjoyed the support of
President Bush during his first term. The House of Representatives passed
legislation twice in 2003 and 2004. However, we were blocked time and time
again by the United States Senate, which would not allow any bill to get to
House-Senate conference committee for discussion.
The goal of our coalition, Doctors for Medical Liability Reform, this past
election cycle was simple: to make a difference in key Senate races. I am very
happy to say that through a coordinated effort by the member associations of
Doctors for Medical Liability Reform, physicians have had a voice on behalf of
their patients for the first time in American history. Our coalition was able
to educate and inform patients, physicians, business leaders, and legislators
about the destructive effects of the medical liability crisis on the nation's
health care and the
economy13. We were
also able to educate the American public on how this crisis affects and will
further affect their access to care. All candidates for national office had to
declare their positions on this issue. At the end of the day, we were able to
have a positive effect. We gained five new "yes" votes for medical
liability reform and won six of eight open Senate races, with all winners
signing the coalition's pledge for medical liability reform.
The president has made this one of his priority issues for his second term.
The next two years will be our window of opportunity to achieve federal
medical liability reform, but we will have to mobilize considerable resources.
The professional unity that we have so successfully achieved over the past
years must move forward for us to capitalize on this success by getting each
and every member of this Academy to contribute to this effort. We can make a
difference and ensure access to care for the American public, but only if each
and every member of this Academy makes the commitment.
Political activism has not traditionally been part of the physician
culture. Many of us have been reluctant to get involved in the political
process directly or by contribution to our Political Action Committee. I will
tell you that our Political Action Committee efforts were critically important
to our success in this past election cycle in these key Senate and
Congressional races, and in getting the first orthopaedic surgeon elected to
Congress. My firsthand experience in fighting for medical liability reform
these past two years has taught me the important lesson that even when we have
the medical liability crisis behind us, we must develop a culture of yearly
contribution to the Political Action Committee.
In the last few minutes, I want to address the collective professional
commitment that we must make to do even more to improve the care we provide to
our patients. As I mentioned at the beginning of this address, I am asking you
to work with me, and with the Academy, to create a culture of patient-centered
care in our organization and in our individual practices. "Nothing About
You... Without You" reflects the essence of this newly evolving
health-care paradigm: patient-centered care.
Patient-centered care is defined as safe, effective, and timely care
achieved through cooperation among the orthopaedic surgeon, an informed and
respected patient (and family), and a coordinated health-care team. In this
paradigm, the patient is the source of control. Knowledge is shared as
information flows freely. Decisions are evidence based. Transparency is
necessary, and cooperation among physicians is a
priority14.
Patient-centered care is the cornerstone of the current quality movement in
health care. Components of patient-centered care, such as decision aids, are
already being tied to reimbursement and to reduced medical liability
premiums15. The
delivery of patient-centered care is part of the responsibility that we
collectively have to our patients. It will require a cultural change within
the Academy and our individual practices.
The development of a culture of patient-centered care within the Academy
and in our individual practices offers physicians the strong probability of
increasing job satisfaction, decreasing liability risk, and increasing patient
satisfaction. From the patient perspective, it ensures better outcomes and
lower health-care
costs15.
What is most exciting about this paradigm is that no other physician group
or specialty society is better poised to play a leadership role in this
movement than the Academy. We have been laying the groundwork for this new
paradigm for the last fifteen years, well before the quality movement began.
It is now time to harness our efforts and take them to the next level by
exercising the physician leadership role in the quality movement. The public
is asking for our help in patient-centered care, and we can ill afford not to
"seize the day."
The development of a patient-centered culture within this Academy and in
our practices requires much of the Academy. We must provide you with the tools
to facilitate the application of science to practice so that you can deliver
evidence-based care. This is not easy. We need to help you know where to find
the best evidence by continuing to work, along with the specialty societies,
on the development of our educational materials, especially the web-based
information.
We need to help you bridge the gap in technology translation so that new
technology can be applied safely and appropriately. This alone is a very
difficult challenge, as technology has advanced faster than we can evaluate
the outcomes of its applications.
The Academy also needs to help you evaluate and react appropriately to
direct-to-consumer advertising. Such advertising is a powerful force in
today's marketplace, and it has a tremendous impact.
Finally, we need to provide you with core competencies required to provide
quality health care under this new
paradigm16,17.
Each of us in our practice encounters thousands of patients each year.
Collectively, we have somewhere between fifteen and twenty million patient
encounters annually. We have a unique opportunity with each patient encounter
to engage patients more actively and enhance these relationships. We have the
opportunity, and in fact the obligation, to provide patients with access to
the authoritative information many of them seek.
All of these opportunities will require the Academy, working along with our
specialty societies, to strengthen our patient education efforts and to take
maximum advantage of changes in information technology to help you in your
practice.
Our educational materials must provide patients with the ability to make
informed choices about treatments through the use of decision aids. Our
educational tools must also help our patients to navigate the treacherous
waters of Internet misinformation, self-promotion advertising, and
direct-to-consumer
marketing18,19.
We need to provide patients with the best evidence available to make these
informed choices. Doing all this will require us to transform our entire
educational culture to one that is evidence based. The best available research
evidence, your clinical expertise, and the patient's values are the
fundamental elements of evidence-based
practice20. The
integration of these elements is increasingly expected of us by those who pay
for health care and rightly by our patients who consume it. We need to be the
authoritative, reliable resource for our patients.
Also, if we are successful in developing the patient-physician partnership,
we will have the unique opportunity to mobilize our patients as a collective
community who will advocate alongside us on issues that will ultimately
benefit them.
Perhaps the most important lesson I have learned over the years as a
physician and as a member of this Academy is that success and accomplishment
come only through partnership. We cannot be successful physicians unless our
focus is on our patients, their needs, and their wishes. We cannot be
successful professionals unless our focus is on our mutual needs and
development of our collective talents.
I am grateful for the responsibility you have invested in me as a leader of
this Academy. I appreciate our past and present achievements, and I promise to
guide us as well as I can into our future success.
To the member who approached me two years ago and said: "Don't forget
about me," I say to you: I haven't and I won't. The American Academy of
Orthopaedic Surgeons is about you and all of us together. It is also,
ultimately and most importantly, about the care and health of our patients. I
will always help to make sure that we remember that commitment so that each
and every one of us can honestly say to our patients: "Nothing about
you... without you."
Thank you very much.